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Running head: COMPARING SUBSTANCE DEPENDENCE STIGMA
Comparing the Stigma of Substance Dependence Disorders in an Undergraduate Population
Matthew D. Machnik
University of Wisconsin-Green Bay
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Abstract
Stigma is a social phenomenon that involves the endorsement of negative attitudes toward
certain groups, such as those diagnosed with mental illness. One such group that falls within the
purview of mental illness is people diagnosed with substance dependence disorders. However,
research into the stigma associated with these disorders is scarce, and even less work has been
done on comparisons of the stigma associated with individual substance dependence disorders.
Thus, the aim of the current study was to expand the knowledge base on this topic by comparing
the stigma associated with nicotine, alcohol, and cocaine dependence. This was accomplished by
examining the stigmatizing beliefs held by a group of undergraduate students at a Midwestern
university. Participants were asked to read one of three vignettes describing an individual
diagnosed with one of the aforementioned conditions, after which they completed two measures
regarding stigma, as well as one regarding familiarity with substance dependence disorders.
Results indicate that cocaine and alcohol dependence were generally rated as having similar
amounts of stigma associated with them, with nicotine dependence being rated as having the
lowest ratings of stigma. Additional results, their potential implications, and limitations of the
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Comparing the Stigma of Substance Dependence Disorders in an Undergraduate Population
Although the conceptualization of stigma is debated, it is proposed that the development
of stigmatizing attitudes involves holding negative and prejudicial beliefs toward members of a
specific group (Link & Phelan, 2001). This can occur based upon general acceptance of
stereotypes held by large groups (Ben-Zeev, Young, & Corrigan, 2010), and can result in
discrimination and status loss (Link & Phelan, 2001). Stigma carries with it a number of
implications for mentally ill individuals, such as stereotyping and prejudice, loss of self-esteem,
and hesitance to seek treatment (Ben-Zeev et al., 2010). The impact of negative stigma on mental
health is so great, advocacy groups, such as the National Alliance on Mental Illness [NAMI],
have undertaken the responsibility of educating the public about mental illness in an attempt to
reduce stigmatizing beliefs held by large groups (NAMI, 2011).
Types of Stigma
Ben-Zeev et al. (2010) take the conceptualization of stigma by Link and Phelan (2001)
further by suggesting that stigma can occur in a number of ways. Specifically, they describe
three different types, including public stigma, self-stigma, and label avoidance (Ben-Zeev et al.,
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Second, it can be thought of as how a person believes that others hold stigmatizing attitudes,
such as when an individual perceives others as believing that drug users are not to be trusted
(Palamar, et al., 2011).
Self-stigma occurs when a person internalizes the stigmatizing beliefs held by the public
(Ben-Zeev et al., 2010), which are then applied by the individual to a stigmatized characteristic
that he or she possesses (Bathje & Pryor, 2011). This internalization can lead to loss of both self-
esteem and self-efficacy (Bathje & Pryor, 2011). As a result, self-stigmatizing individuals may
experience decreased confidence regarding the completion of everyday tasks, as well as
hesitance to seek treatment (Ben-Zeev et al., 2010).
Finally, label avoidance occurs when a person engages in behavior aimed at avoiding the
application of a stigmatized label applied to him or her (Ben-Zeev et al., 2010). For example, a
person may choose to not seek treatment for his or her mental illness due to the impact of being
labeled as a mental health patient (Ben-Zeev et al., 2010). Based on the conceptualizations
provided by Ben-Zeev et al. (2010), label avoidance could be the product of either public or self-
stigma. In other words, a person may want to avoid a label that was applied either by the public,
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employers may be hesitant to hire individuals diagnosed with mental illness, while landlords may
not lease to them out of concern for tenant safety (Ben-Zeev et al., 2010). This, it would seem,
may result from the perception that persons with mental illness are inherently dangerous (Link &
Phelan, 2001). In addition, stigmatized individuals can experience a greater desire for social
distance by others (Dietrich et al., 2004), which can impair social relationships. If these
stigmatizing beliefs are internalized, they may be hesitant to engage in social situations, leading
to outright social avoidance (Ben-Zeev et al., 2010). Thus, it is apparent that developing an
understanding of stigma is imperative, as stigma can discourage treatment, create economic
disadvantages, and lead to a lower quality of life among those diagnosed with mental illness.
Two of the most commonly studied disorders in regard to mental illness stigma are
schizophrenia and depression. Studies have been conducted that suggest stigma associated with
schizophrenia exists on a variety of levels, including publically (Smith, Reddy, Foster, Asbury,
& Brooks, 2011), and self-directed among diagnosed individuals (Kleim et al., 2008). Interviews
conducted with persons diagnosed with schizophrenia suggest that these stigmatizing beliefs can
lead to social isolation and discrimination, being perceived as dangerous, and receiving
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Stigma and Substance Use
Stigmatizing beliefs have also been studied in regard to substance abuse disorders,
although this particular group has received less attention than others. This lack of attention may
be a point of concern, since substance disorders are regarded as being highly destructive to the
individual (Geppert & Bogenschutz, 2009). The desire to avoid labeling may discourage these
individuals from seeking treatment (Ben-Zeev et al., 2010), however, which can allow the
destructive behavior to continue. In addition, the results of a study conducted by Luoma et al.
(2007) suggest that people who seek treatment for substance related disorders are often aware of
their stigmatization, which may decrease the likelihood of treatment success. Thus, not only is
stigma a barrier to seeking treatment, but it may also act as a source of discouragement after
treatment has begun.
Stigma has also been examined regarding specific substance types and their related
disorders. Stigma associated with nicotine use, cigarette smoking in particular, has become an
area of interest recently, as legislation has begun to prohibit smoking in public areas (Kim &
Shanahan, 2003). Although the objective of this process is to encourage current smokers to quit,
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work supervisors as being lower on job performance and dependability (Gilbert, Hannan, &
Lowe, 1998). Furthermore, in a study conducted by Stuber & Galea (2009), a strong relationship
was found between negative perceptions of the social acceptability of smoking, and reluctance to
discuss smoking habits with primary care physicians. Therefore, when considering the impact of
anti-smoking campaigns and legislation on stigma, the possibility exists that increases in stigma
may actually deter smoking cessation efforts.
Another area that has received a considerable amount of attention is stigma associated
with alcohol use. Studies have been conducted to confirm the presence of publically held
stigmatizing beliefs about people who abuse alcohol across different cultures (Piza Peluso, &
Blay, 2008; Fortney et al., 2004). Similar to other disorders, the perceived shame resulting from
stigma associated with seeking treatment for alcohol related disorders can deter individuals from
finding care (Gray, 2010). The results of a study conducted by Fortney et al. (2004) suggest that
these stigmatizing beliefs can occur regardless of treatment venue, whether it is specialized or
through primary care.
Moreover, research has examined the public stigma associated with alcohol dependence.
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racial differences in perceptions of former alcoholics. The results of the study indicate that White
respondents reported holding fewer stigmatizing beliefs toward former alcoholics when
compared with minority group members (Smith et al., 2010). Interestingly, a study conducted by
Fortney et al. (2004) found that African-American individuals were less likely to feel stigmatized
upon seeking treatment for alcohol abuse when compared to Caucasians.
The results of the aforementioned studies provide interesting insight into the stigma held
by different racial groups. Specifically, even though African-American individuals hold more
stigmatizing beliefs about alcohol use (Smith et al., 2010), they are less likely to feel stigmatized
for seeking treatment (Fortney et al., 2004). The inverse appears to be true for White/Caucasian
individuals (Smith et al., 2010; Fortney et al., 2004). Although one can speculate on what might
cause these seemingly paradoxical findings, it is difficult to infer what might cause this
relationship. Therefore, it seems that additional research is needed to explain these results.
Nevertheless, both studies have provided information demonstrating the complex nature of
stigma as it relates to substance abuse.
A thorough search of the relevant literature yielded no information pertaining solely to
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Currently, there is a lack of information in the literature pertaining to comparisons of
substance dependence and other mental illnesses. However, existing research does provide some
insight into this issue. For instance, studies conducted by Corrigan et al. (2000) and Crespo et al.
(2008) made use of similar measures of stigma, and found that cocaine use was consistently rated
as holding more stigma than psychosis and depression. One potential explanation for this finding
comes from a vignette study conducted by Link, Phelan, Bresnahan, Stueve, and Pescosolido
(1999), in which results suggest that persons diagnosed with substance dependence disorders
were perceived as being more likely to exhibit violent behavior when compared with persons
diagnosed with depression. In addition, a vignette study conducted by Pescosolido et al. (2010)
found that alcohol dependence was a more stigmatized condition than schizophrenia. Thus,
although specific research into this area is rare, it would appear that substance abuse is
considered to be a more stigmatized condition than some other forms of mental illness.
One explanation for these results involves examining other perceptions of mental illness
and substance disorders. For example, Link et al. (1999) found that participants were less likely
to rate cocaine or alcohol dependence as a mental illness when compared to depression or
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Comparison of Substance Related Stigma
Another gap in our knowledge base pertains to comparisons of the stigma of individual
substance disorders. However, the small amount of existing research on this topic can provide
limited insight. For example, Link et al. (1999) examined the stigmatizing attitudes toward a
number of different psychiatric and medical conditions. Although this study was mentioned
previously, it is unique in that it included multiple substance use disorders in its comparison,
whereas others limited their inclusion to a single substance related disorder. Therefore, the study
conducted by Link et al. (1999) is one of few that can provide information related to
comparisons of substance use stigma.
Utilizing a nationwide, representative sample of American adults (N=1444), Link et al.
(1999) presented participants with a number of different vignettes. Each vignette was written to
represent an individual diagnosed with a specific condition, such as cocaine dependence, alcohol
dependence, or schizophrenia, with each disorder being representative of the diagnostic criteria
in the DSM-IV (Link et al., 1999). In addition, baseline measurements of stigma were derived
from a vignette describing a troubled individual who was not diagnosed with any condition (Link
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A number of different results were obtained regarding the stigma of cocaine and alcohol
dependence. Specifically, persons described as being diagnosed with cocaine dependence were
perceived as being more likely to be violent when compared with persons diagnosed with alcohol
dependence (Link et al., 1999). Similarly, participants responded as desiring greater amounts of
social distance from an individual diagnosed with cocaine dependence when compared to an
individual diagnosed with alcohol dependence (Link et al., 1999). Therefore, one can conclude
that, according to the results of Link et al. (1999), cocaine dependence as a diagnosed condition
is more stigmatized than alcohol dependence.
A more thorough approach to comparing stigmatizing beliefs about substance use was
conducted by Cunningham, Sobell, and Chow (1993). The researchers utilized a participant pool
of 606 adults, aged 19 to 76, who were recruited locally. The researchers departed from other
research methods by using vignettes describing a general substance use scenario, rather than
basing the vignettes on DSM-IV criteria (Cunningham et al., 1993). In constructing the vignettes,
the researchers described a male individual who engaged in one of three types of substance use,
including cigarette smoking, alcohol consumption, or cocaine use (Cunningham et al., 1993). In
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marital aspects, and two for interpersonal (Cunningham et al., 1993). This allowed comparisons
to be made across the different aspects of stigma, which offered insight into whether a substance
type was stigmatized more greatly in one area as opposed to another. Finally, the researchers
collected information regarding substance abuse treatment, and how it pertained to the individual
in the vignette (Cunningham et al., 1993). Specifically, the questions assessed impressions of
likelihood of treatment success, which types of treatment programs they would suggest, whether
or not the individual could successfully cease substance use by abstaining, and whether or not
participants would believe the individual described if he admitted to successfully ceasing his
substance use (Cunningham et al., 1993).
The researchers reported a number of significant findings. In regard to treatment, cocaine
and alcohol users were rated as being less likely to succeed in treatment when compared to
cigarette smokers (Cunningham et al., 1993). Across all three substance types, individuals
utilizing abstinence for cessation of use were rated as being more likely to succeed than those
undertaking non-abstaining methods (Cunningham et al., 1993). Finally, cigarette smokers were
rated as being more likely to succeed in cessation of use without treatment when compared to
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by Cunningham et al. (1993), it would appear that cigarette smokers are subjected to lower levels
of stigma when compared to cocaine or alcohol users.
The researchers provided a number of potential explanations for their results.
Specifically, in regard to cigarette smoking being rated as less likely to cause problems across all
elements of stigma, the authors suggest that this finding may have originated from participants
belief that cigarette smoking is not a legitimate substance abuse problem (Cunningham et al.,
1993). This may be so, given the less stringent restrictions placed on tobacco when compared to
cocaine or alcohol use. In addition, this perception may also be supported by the notion that
tobacco use is seemingly associated with fewer intoxicating and behavior influencing effects
than the other two substance types used.
The researchers were surprised by the finding that cocaine and alcohol use were rated as
having similar amounts of legal stigma (Cunningham et al., 1993). They suggest that this
perception may have come about by participants considering the legal ramifications associated
with each, such as drunk driving and arrests (Cunningham et al., 1993). Though this certainly
seems plausible, the result also carries with it a potential implication for stigma and the legal
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similarities exist, certain differences do as well. For example, in both studies, individuals using
cocaine were rated as being highly stigmatized (Link et al., 1999; Cunningham et al., 1993).
However, whereas cocaine dependence was associated with a higher degree of stigmatization
than alcohol dependence in Link et al. (1999), cocaine users were ascribed a similar level of
stigmatization when compared to alcohol users in Cunningham et al. (1993). Thus, the results of
the two studies suggest that cocaine and alcohol use carry similar levels of stigma in some
populations, but not others.
Observations of methodological differences between the two studies may provide a
potential explanation for their differing results. First, both studies made use of different
populations. Specifically, the participant pool used in Link et al. (1999) was comprised of adults
who participated in a survey that was administered throughout the United States, whereas the
study conducted by Cunningham et al. (1993) was completed using adults recruited locally in
Toronto, Canada. Therefore, given the different countries of origin for both samples, one
potential explanation for the different results regarding cocaine and alcohol related stigma is that
they represent different culturally held beliefs. While this suggestion is certainly debatable, it
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Cunningham et al. (1993) were constructed to describe patterns of substance use not
corresponding to a diagnosed condition. The presentation of different behaviors in both studies
may play a role in affecting how participants view the individuals described in the vignettes, and
may account for the differences present. Therefore, it may be prudent to suggest that researchers
hoping to make comparisons between obtained and previous results use similar criteria for
presenting behaviors.
A final difference is present in the types of measurements used. For example, the measure
used in Cunningham et al. (1993) focused on the social consequences of substance use, such as
problems in regard to work, legal, marital, and interpersonal issues. However, the measure used
in Link et al. (1999) assessed perceptions of dangerousness, as well as desire for social distance.
Thus, differences in the aspects of stigma that were assessed in the two studies may have
contributed to the differences in the results.
The Current Study
The current investigation served as a partial conceptual replication of the study conducted
by Cunningham et al. (1993). This is because, similar to Cunningham et al. (1993), the intention
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al. (1993). The population used in the current research contained a number of distinct differences
when compared to the original study. For example, it was comprised entirely of undergraduate
students at a local university, was located in a different country and state of origin, and had a
distinct prevalence rate of substance use (Wisconsin Department of Health Services [WDHS],
2010). Specifically, Wisconsin has the highest rates of overall alcohol consumption, binge
drinking, and drinking and driving in the United States (WDHS, 2010). It was hypothesized that
these differences would have a cumulative effect that influenced the results obtained. For
example, given the high prevalence of alcohol consumption in this region, it was proposed that
stigmatizing attitudes about alcohol use may be lower due to the seemingly high social
acceptability of this behavior.
In addition, the population used in the current research was more representative of
undergraduate students. For example, average participant age was 19.66 (SD=3.05), whereas the
population used in Cunningham et al. (1993) was reported as having an average age of 29.1
(SD=9.3). Furthermore, all of the participants will have attained some level of college education,
whereas only 58.1% (N=579) of the population in Cunningham et al. (1993) reported having
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seem unlikely that the brief questionnaire used in Cunningham et al. (1993) is adequate in
forming a clear understanding of stigma. This may be especially true, since three of the four
elements were assessed using only a single question. In addition, researchers have proposed that
different types of stigma may exist, including public and self-stigma, as well as label avoidance
(Ben-Zeev et al., 2010). These types of stigma can be broken down further to include concepts
such as dangerousness, helping or rejection behaviors, and ideas regarding segregation of the
mentally ill (Corrigan et al., 2003a). Therefore, advances in the understanding of stigma have
seemingly rendered the measure used by Cunningham et al. (1993) inadequate, in that it does not
address the different facets of stigma that have been proposed. These same limitations could be
applied to the measure used in Link et al. (1999), who limited their assessment of stigma to
perceptions of dangerousness and desire for social distance. Therefore, the current study
attempted to overcome the limitations of both Cunningham et al. (1993) and Link et al. (1999) by
including assessments for two different types of public stigma, including the specific beliefs held
by the participants, as well as how participants believe others view mentally ill persons.
Finally, the current study utilized vignettes derived from the DSM-IV-TR criteria for
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use, whereas this behavior is not present in the vignette for alcohol dependence (Link et al.,
1999). Thus, it is possible that participants ratings of stigma may have been influenced by the
behaviors presented, such as theft, as opposed to the disorder described. Therefore, the current
study attempted to overcome this limitation by keeping the descriptions of behavior consistent
throughout each of the vignettes. By doing so, it was proposed that participants ratings would be
more indicative of the attitudes held toward the different substance dependence disorders rather
than the behaviors described.
The present study tested three different hypotheses. First, it was hypothesized that
nicotine dependence would carry with it the lowest ratings of stigma. This is based upon the
notion that participants may associate nicotine use with fewer intoxicating effects and legal
ramifications. Second, it was hypothesized that alcohol dependence would be rated as having
more stigma than nicotine dependence, but less stigma than cocaine dependence. Although this
stands in contrast to the results obtained by Cunningham et al. (1993), it was proposed that the
characteristics of the population being used will contribute to decreased amounts of stigma
associated with alcohol. Finally, it was hypothesized that cocaine dependence would be
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N=143) were in their first or second year of undergraduate schooling. Ethnically, the vast
majority of the population identified as White/Caucasian (N=145; 89.5%). However, other
ethnicities were represented, including Asian/Pacific Islander (N=7; 4.3%), Black/African-
American (N=2; 1.2%), Hispanic/Mexican/Puerto Rican (N=3; 1.9%), Native American (N=3;
1.9%), and 2 participants (1.2%) identifying as other. Finally, 32 different undergraduate majors
were represented, with 44 participants (27.2%) responding undecided, and 7 (4.3%) providing
no information regarding their majors. The three most commonly represented majors in the
sample were Human Biology (N=19; 11.7%), Nursing (N=12; 7.4%), and Human Development
(N=11; 6.8%).
Although the total number of respondents was 163 individuals, one was eliminated from
data analysis for reporting an age less than 18 years, which resulted in the final sample size of
162. Furthermore, only 160 students signed up in advance to participate in the study, which was
the only way to receive the web link to the surveys. That means some may have taken the
surveys twice. All of the participants were recruited using the Experiential Research Learning
Program [ERLP], a computer-based program designed at the university where the study took
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Data collection was completed over the Internet using Qualtrics survey software. Upon
signing up for the study in ERLP, each participant was provided with a link to the study website.
Use of this method allowed each participant to complete the survey at a time and place of his or
her choosing. Once at the study website, each of the participants was asked to read a consent
form (see Appendix A). Consent was obtained on this form using a forced-choice checkbox
which, if not checked, would not allow students to progress past this point. If they consented,
they were then asked to provide demographic information, including age, gender, ethnicity,
major, and year in school (see Appendix B). Next, following a between-subjects design,
participants were randomly assigned to read one of three vignettes developed by the researcher.
Randomization was accomplished using a setting within the Qualtrics survey software, which
allowed each vignette to be distributed a proportionate number of times throughout the entire
participant pool. After reading the vignette, participants were asked to complete three different
questionnaires regarding their attitudes toward the person in the vignette, as well as their
familiarity with substance dependence disorders.
After completing each of the surveys, the responses were saved, and participants were
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(see Appendix D). The three disorders used were derived from theDiagnostic and Statistical
Manual of Mental Disorders, 4th
Edition, Text Revision [DSM-IV-TR], and consisted of alcohol
dependence, cocaine dependence, and nicotine dependence (American Psychiatric Association,
2000). The final number of participants exposed to each vignette was as follows: cocaine
dependence (N=53), alcohol dependence (N=55), and nicotine dependence (N=54). Within the
nicotine dependence vignette, cigarette smoking was described as the preferred means of
nicotine administration. Each of the vignettes contained similar descriptions of behavior, and the
manipulation was the type of substance dependence with which the person was diagnosed.
Questionnaires.
Attribution Questionnaire. This measure was developed by Corrigan et al. (2003a), and
was used in the current research to assess the stigmatizing attitudes held by each participant (see
Appendix E). The questionnaire included six different subscales which were designed to assess a
number of different components of stigma, including personal responsibility beliefs (3 items),
pity (3 items), anger (3 items), fear (4 items), coercion-segregation (4 items), and willingness to
help (4 items) (Corrigan et al., 2003a). Each of the 21 items was scored using a nine-point Likert
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fear = .96; helping = .88; and coercion/segregation = .89 (Corrigan et al., 2003a). Normative data
was provided for four of the six subscales: personal responsibility (M=4.32, SD=2.14); pity
(M=5.55, SD=1.94); anger (M=3.77, SD=2.19); fear (M=5.07, SD=2.49).
DUSS. The DUSS was developed by Palamar et al. (2011), and was used to assess
participants beliefs regarding perceptions of stigma held by others (see Appendix F). The 10
items in the DUSS were designed to measure several different facets of public stigma, including
dangerousness, trust, and likelihood of finding employment (Palamar et al., 2011). Participants
were asked to rate how much they agreed with each item using a five-point Likert scale (Palamar
et al., 2011). An overall score of stigma was formed by adding the responses, and dividing the
sum by the total number of items (score range = 1 to 5; Palamar et al., 2011). In addition to
providing a measure of public stigma, the DUSS addressed the possibility that participants may
be more comfortable ascribing stigmatizing beliefs to others.
The psychometric properties of the DUSS were assessed using a sample of 1,048 adults
[mean age=20.31 (SD=1.9); 43.6% identified as White; 46.4% had some college education;
Palamar et al., 2011]. However, the only psychometric information obtained was in regard to the
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the 7 items were modified, with the authors permission, to reflect familiarity with substance
dependence disorders. Participants were asked to provide a yes or no response. Responses were
summed together, with yes responses adding one point to the overall total, and no responses
being marked as zero (Corrigan et al., 2003a). This method produced a familiarity index that
ranged from a minimum of zero points, to a maximum of seven (Corrigan et al., 2003a). This
measure was found to have acceptable reliability ( = .62) , and was normed using the same
sample as the Attribution Questionnaire, with a mean score of familiarity being reported as 2.17
(SD=1.63; Corrigan et al., 2003a).
Results
Data were analyzed using IBM SPSS 19 Statistics software. Before the dependent
variables were analyzed, the demographic distribution of each experimental condition was
examined. A one-way ANOVA was used to determine the means and standard deviations for the
age and year in school variables across the three experimental conditions. Furthermore, a Chi-
Square analysis was performed to determine if the distribution of gender and ethnicity were
different across the experimental conditions as well. No statistically significant differences were
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.001), coercion-segregation (p < .001), and personal responsibility (p < .01) subscales of the
Attribution Questionnaire, as well as on the DUSS (p < .001). Differences between conditions on
the pity and anger subscales of the Attribution Questionnaire, as well as the familiarity
questionnaire, were not statistically significant. In addition, a post hoc Tukey HSD Comparison
was run to further examine differences between conditions on scores of stigma and familiarity,
and a number of significant results were obtained (see Table 3).
A bivariate correlation analysis was run to determine the relationships between the
summed scores for the six subscales of the Attribution Questionnaire, DUSS, and familiarity
questionnaire. Numerous statistically significant relationships emerged, but perhaps the most
noteworthy are the relationships found between familiarity scores and the measures of stigma.
With the exception of the personal responsibility subscale, all other measures of stigma were
significantly correlated with familiarity in such a way that overall stigmatizing beliefs were
reduced as familiarity increased. The correlation matrix associated with this analysis is provided
in Table 4.
Finally, analyses were run to determine whether any significant differences were present
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analysis was run to examine any potential relationships between age, year in school, and summed
scores on the stigma and familiarity questionnaires. The only significant relationship to emerge
was between age and the personal responsibility subscale (r= -.16,p < .05), suggesting that
perceptions of personal responsibility tended to decrease as age increased. Since the average age
was relatively similar between each of the three conditions, it is not likely that this relationship
had a significant effect on comparisons of mean ratings of personal responsibility between
conditions.
Discussion
The purpose of the current study was to compare ratings of stigma associated with
cocaine, alcohol, and nicotine dependence disorders. Results of the data analysis supported the
hypothesis that nicotine dependence would, in relation to the other substance types, carry the
lowest levels of stigma within the population studied. Specifically, nicotine dependence was
associated with lesser degrees of fear and coercion-segregation beliefs, lower scores of perceived
stigmatizing beliefs of others, and an increased willingness to help. However, nicotine
dependence was rated as having a higher degree of personal responsibility, suggesting that
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dependence may suggest social acceptability of the behavior. This, in turn, could create a
situation in which nicotine dependent persons feel less social pressure to cease nicotine use.
Thus, while stigma has been noted to have the effect of creating hesitance to seek mental health
treatment (Ben-Zeev et al., 2010), it may be the case that individuals with less stigmatized
conditions may perceive less social pressure to seek treatment for cessation of use. One potential
direction for future research may be to examine the relationship between a lack of perceived
stigma in regard to substance dependence and willingness to cease substance use.
The results regarding the second and third hypotheses were mixed. It was proposed that
cocaine dependence would be associated with the highest ratings of stigma, while alcohol
dependence would be less stigmatized than cocaine dependence, but more stigmatized than
nicotine dependence. While cocaine dependence was associated with higher levels of stigma in
regard to fear and personal responsibility, relatively similar ratings of stigma for cocaine and
alcohol dependence were found in regard to helping, coercion-segregation beliefs, and the
perceived beliefs of others. Thus, while support was obtained for hypotheses two and three, this
support is fairly limited.
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potentially be attributed to the increased prevalence of alcohol consumption in the current
sample, it cannot be known for certain. One suggestion for future research would be to perform
studies of substance dependence stigma using similar methodologies. For example, a number of
studies done using the same measures, and in different geographic locations, could then be
compared to determine whether the differences in scores of stigma could be attributed to
population differences. From this, it could be determined if a regions prevalence of substance
use could affect stigmatizing attitudes.
One result that was particularly troublesome was the strong negative correlation between
helping behaviors and the perceived stigmatizing beliefs of others. This carries the important
implication that an individuals willingness to engage in helping behaviors (e.g., sharing a car
pool or offering a job interview) toward persons diagnosed with substance dependence disorders
may be influenced by the stigmatizing attitudes that he or she believes others hold. However, a
more positive result was found when comparing familiarity with substance dependence disorders
and scores of stigma. Specifically, stigmatizing beliefs were reduced as increased familiarity was
reported. Thus, while the correlations were not particularly strong in this regard, they were
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is needed to determine how to effectively increase familiarity with substance dependent
individuals. For example, one way to possibly increase familiarity could be through live lectures
or videos of personal testimonials. These methods, however, are different from the examples of
exposure described in the familiarity questionnaire, which makes their ability to increase
familiarity questionable. Nevertheless, future research may want to examine these methods as a
potential means of increasing familiarity with persons diagnosed with substance dependence
disorders, since, as the results of this study would suggest, increasing familiarity could reduce
stigmatizing attitudes.
One particularly intriguing result was in regard to the pity and anger subscales of the
Attribution Questionnaire, in that the mean responses for each deviated from the trends present
in the remaining four subscales, as well as the DUSS. Specifically, the trend involved cocaine
and alcohol dependence being rated as having relatively similar levels of stigma on three scales,
with alcohol dependence having slightly lower ratings of stigma on two scales. In deviating from
this trend, alcohol dependence was rated as having higher mean scores of pity and anger than
both cocaine and nicotine dependence. In other words, participants reported feeling more
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While the measures used in this study were intended to provide a thorough measurement
of stigma, there are additional variables not accounted for which could have affected scores. Onesuch variable is the influence of the legal status of a substance. For example, cocaine is currently
an illicit substance, while alcohol and nicotine products are legally obtainable. Although it is
possible that the current research may provide some insight into this issue, the methodology of
the study makes it difficult to understand directly the contributions of legal status to stigma.
Thus, it would seem that researchers hoping to develop a better understanding of stigma may
want to pursue this specific topic of inquiry.
Additionally, due to ethical reasons, the participants own habits of drug use were not
recorded. One could assume that if, for example, one of the participants was a frequent user of
any of the substances mentioned in this study, he or she may be less likely to give higher ratings
of stigma. Furthermore, participants with different patterns of substance use, such as binge
drinking or heavy consumption, could result in different ratings of stigma within each of the
substance types used. For this reason, it is suggested that any future research on the subject of
substance dependence stigma include measures of personal substance use, and examine patterns
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make these comparisons. Nevertheless, this brief and informal comparison is able to provide
some insight into where substance dependence stands in regard to mental illness stigma.Several limitations are present within the current study. First, the vignettes that were used
only addressed stigmatizing attitudes directed toward males with substance dependence
disorders. Therefore, future studies of this type should include both male and female characters
in vignettes to determine any differences that may exist based on gender. Second, the measure
developed by Palamar et al. (2011) was designed specifically to assess stigmatizing attitudes
toward people who use illicit substances. Therefore, although reliability and validity information
was available regarding its use measuring the stigma of cocaine dependence, its ability to
measure the stigma of both nicotine and alcohol dependence is questionable. Thus, the
measurements obtained regarding nicotine and alcohol dependence may not be entirely accurate.
It is suggested the psychometric properties of the scale developed by Palamar et al. (2011) be
investigated further, as it may serve as a powerful measure of stigma directed toward users of
non-illicit substances. Third, the sample used in the study was predominantly White/Caucasian.
Therefore, the results may not be generalizable to undergraduate populations with greater
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beliefs develop, in that comparisons of stigma across populations with different characteristics,
such as substance use prevalence rates, can possibly identify factors that contribute to increasedor decreased stigma. It is hoped that this study will inspire others to follow suit, and help build a
better understanding of public stigma.
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Perceptions of discrimination among persons with serious mental illness. Psychiatric
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Stigma and discrimination towards people with schizophrenia and their family members:
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(2007). An investigation of stigma in individuals receiving treatment for substance abuse.
Addictive Behaviors, 32, 1331-1346. doi:10.1016/j.addbeh.2006.09.008National Alliance on Mental Illness (2011). NAMI: National Alliance on Mental IllnessMental
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Stuber, J., & Galea, S. (2009). Who conceals their smoking status from their health care
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Appendix APlease print this form for your records.
Informed Consent*
Please read the following information carefully:
Title: College Students Attitudes about Substance Dependence
Principal Investigator: Dr. Kristin Vespia; [email protected]; (920) 465-2746
Research Assistant: Matthew D. Machnik
Purpose of Research: To gain knowledge pertaining to students attitudes toward persons diagnosed withsubstance dependence disorders. This research is taking place under the supervision of Dr. Kristin Vespia,a faculty member in Human Development and Psychology, and is part of an Honors Project beingconducted by Matthew D. Machnik, a UWGB student.
Participation: Participation will involve reading a vignette and completing four brief surveys, whichshould take about 15 minutes in total. The first survey will collect demographic information, includingage, gender, ethnicity, major, and year in school. Two questionnaires will ask about personal and publicperceptions related to substance dependence disorders. A final measure will include items aboutparticipants familiarity with substance dependence disorders.
Benefits: Participants will receive 1 ERLP point for their participation.
Risks: The only foreseeable risks involved with this study will be the minimal risk typically associatedwith survey research that encountering survey items on a topic that somehow relates to your own
background could potentially, for example, lead you to think more about that background as a result.Please stop your participation and contact the research supervisor if you experience any distress.
Safeguards: All survey information provided will be anonymous and will be kept confidential Although
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Appendix B
1. Age ______
2. Gender: (Please circle one)
Male Female
3. Which of the following best describes your ethnic affiliation: (Please check one)
___ Asian/Pacific Islander
___ Black/African-American
___ Hispanic/Mexican/Puerto Rican
___ Native American
___ White/Caucasian
4. Current major: ____________________________
5. Year in school: (Please check one)
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Appendix C
If you did not already print the consent form, please take this opportunity to print the followinginformation for your records.
Thank you for participating in the study! The following information reiterates the purpose of the
study in which you just participated, and provides the contact information for the researchers
involved should you have any questions.
Title: College Students Attitudes about Substance Dependence
Purpose of Research: To gain knowledge pertaining to students attitudes toward persons
diagnosed with substance dependence disorders. This research is taking place under the
supervision of Dr. Kristin Vespia, a faculty member in Human Development and Psychology,
and is part of an Honors Project being conducted by Matthew D. Machnik, a UWGB student.
Posting of Results: The results of the study will be posted on the ERLP website once data
collection is complete. If you have questions regarding the study, or would like to be notified
about the results individually, please contact Dr. Kristin Vespia; [email protected]; (920) 465-
2746.
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Appendix D
Cocaine Dependence:
Thomas has been using cocaine for the past 18 months. During the past 12 months, he has
needed to increase the amount of cocaine he uses in order to achieve the desired effect. He finds
that when he is unable to use cocaine, he experiences significant cocaine withdrawal symptoms.
In order to overcome the withdrawal, he feels he needs to use cocaine on a continual basis. Hehas noticed a marked decline in his overall health, and has all but given up the recreational
activities he used to enjoy. Even though he is aware of the effects his cocaine use is having on
his life, he continues to use it. Over the past 12 months, he has tried to quit using cocaine several
times, but has been unsuccessful. As a result, Thomas has been diagnosed by a Psychologist as
having cocaine dependence.
Alcohol Dependence:
Thomas has been drinking alcohol for the past 18 months. During the past 12 months, he has
needed to increase the amount of alcohol he drinks in order to achieve the desired effect. He
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Appendix D (continued)
Nicotine Dependence:Thomas has been smoking cigarettes for the past 18 months. During the past 12 months, he has
needed to increase the number of cigarettes he smokes in order to achieve the desired effect. He
finds that when he is unable to smoke cigarettes, he experiences significant nicotine withdrawal
symptoms. In order to overcome the withdrawal, he feels he needs to smoke cigarettes on a
continual basis. He has noticed a marked decline in his overall health, and has all but given up
the recreational activities he used to enjoy. Even though he is aware of the effects his cigarette
smoking is having on his life, he continues to smoke. Over the past 12 months, he has tried to
quit smoking cigarettes several times, but has been unsuccessful. As a result, Thomas has been
diagnosed by a Psychologist as having nicotine dependence.
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Appendix E
Personal Responsibility Beliefs1. I would think that it were Thomass own fault that he is in the present condition. (1 = No, not
at all; 9 = Yes, absolutely so)
2. How controllable, do you think, is the cause of Thomass present condition? (1 = Not at all
under personal control; 9 = Completely under personal control)
3. How responsible, do you think, is Thomas for his present condition? (1 = Not at all
responsible; 9 = Very much responsible)
Pity
1. I would feel pity for Thomas. (1 = None at all; 9 = Very much)
2. How much sympathy would you feel for Thomas? (1 = None at all; 9 = Very much)
3. How much concern would you feel for Thomas? (1 = None at all; 9 = Very much)
Anger
1. I would feel aggravated by Thomas. (1 = None at all; 9 = Very much)
2. How angry would you feel at Thomas? (1 = None at all; 9 = Very much)
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Appendix E (continued)
Helping1. If I were an employer, I would interview Thomas for a job. (1 = Not likely; 9 = Very likely)
2. I would share a car pool with Thomas each day. (1 = Not likely; 9 = Very likely)
3. How certain would you feel that you would help Thomas? (1 = Not at all certain; 9 =
Absolutely certain)
4. If I were a landlord, I probably would rent an apartment to Thomas. (1 = Not likely; 9 = Very
likely)
Coercion-Segregation
1. I think Thomas poses a risk to his neighbors unless he is hospitalized. (1 = Not at all; 9 = Very
much)
2. I think it would be best for Thomass community if he were put away in a psychiatric hospital.
(1 = Not at all; 9 = Very much)
3. How much do you think an asylum, where Thomas can be kept away from his neighbors, is
best? (1 = Not at all; 9 = Very much)
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Appendix F
For all items, 1 = Strongly disagree; 5 = Strongly agree
1. Most people would believe Thomas cannot be trusted.
2. Most people would believe that Thomas is dangerous.
3. Most people would not accept Thomas as a close friend.
4. Most people feel that Thomass drug use is a sign of personal failure.
5. Most people would take Thomass opinion less seriously.
6. Most people think less of Thomas.
7. Most people would treat Thomas just as they would treat anyone else.
8. Most employers would not hire Thomas.
9. Most people would not accept Thomas as a teacher of young children in public schools.
10. Most young women would not date Thomas.
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Appendix G
1. My job involves providing services/treatment for persons with substance dependence
disorders. (Yes/No)
2. I have observed, in passing, a person I believe may have had a substance dependence disorder.
(Yes/No)
3. I have observed persons with substance dependence disorders on a frequent basis. (Yes/No)
4. I have worked with a person who had a substance dependence disorder at my place of
employment. (Yes/No)
5. A friend of the family has a substance dependence disorder. (Yes/No)
6. I have a relative who has a substance dependence disorder. (Yes/No)
7. I live with a person who has a substance dependence disorder. (Yes/No)
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Table 1
Age and Year in School Distribution between Conditions
Cocaine Alcohol Nicotine
M SD M SD M SD
Age 20.04 4.53 19.51 2.23 19.42 1.61
Year in School 1.51 1.07 1.58 1.05 1.39 0.79
Note. No statistically significant differences were found between conditions.
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Table 2
Gender and Ethnicity Distribution between Conditions
Cocaine Alcohol Nicotine
N N N
Gender
Male 12 12 13
Female 40 43 41
Other 1 0 0
Ethnicity
Asian/Pacific Islander 2 4 1
Black/African-American 0 0 1
Hispanic/Mexican/Puerto Rican 1 2 0
Native American 2 0 1
White/Caucasian 47 48 50
Other 1 1 1
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Table 3
Means and Standard Deviations of Measures with Tukey HSD Comparison Significance Levels
Cocaine Alcohol Nicotine
Measures M SD M SD M SD
Attribution Questionnaire
Pity 4.82 1.62 5.18 1.6 4.58 1.74
Anger 4.77 2.15 5.28 2.08 4.76 2.13
Fear 4.51 c. ** 1.71 4.13 c. **
1.74 2.73 a. ** b. ** 1.59
Helping 3.39 c. ** 1.42 3.32 c. ** 1.14 4.48 a. ** b. ** 1.7
Coercion-Segregation 3.76 c. ** 1.52 3.14 c. * 1.46 2.4 a. ** b. * 1.42
Personal Responsibility 5.98 c. * 1.68 6.1 1.39 6.75 a. * 1.17
DUSS 3.96 c. ** 0.46 3.99 c. ** 0.49 3.08 a.** b. ** 0.67
Familiarity Questionnaire 2.42 1.66 2.78 1.77 2.65 1.78
Note. Only statistically significant relationships are reported. a. = compared to cocaine dependence, b.= compared to alcohol
dependence, c. = compared to nicotine dependence, * = p < .05, ** =p < .001
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Table 4
Correlations between Summed Scores on all Measures
Measures 1 2 3 4 5 6 7 8
1 Personal Responsibility --- ***-.34 ***.37 .11 *-.16 .10 -.01 -.13
2 Pity --- *-.16 .01 ***.30 *-.17 -.03 *.17
3 Anger --- ***.36 -.12 ***.31 .14 *-.17
4 Fear --- **-.23 ***.63 ***.44 *-.18
5 Helping --- **-.21 ***-.50 *.18
6 Coercion-Segregation --- ***.40 ***-.26
7 DUSS --- **-.23
8 Familiarity ---
Note. * =p < .05, ** =p < .01, *** =p < .001
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